7/5/2017 OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE School of Medicine Division of Geriatrics The Other Half of the Fracture Equation: Fall Prevention and Management Anna Chodos, MD, MPH Geriatrics, Zuckerberg San Francisco General Hospital Anna.Chodos@ucsf.edu July 21, 2016 SECTION HEADING Presenter Disclosure Information Anna Chodos • No relevant disclosures School of Medicine 2 1
7/5/2017 SECTION HEADING Presentation Outline • Case presentation • Prevalence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 3 SECTION HEADING Presentation Outline • Case presentation • Prevalence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 4 2
7/5/2017 Case Mr. S is an 83 year old man with of hypertension, osteoporosis, alcohol use disorder and multiple falls who presents with a fall and L1 compression fracture with fragment retropulsion and need for spinal fusion. School of Medicine 5 • He has had 5 falls in the last year. Indoor falls are associated with shifts in position and feeling off-balance. These falls are not associated with loss of consciousness, palpitations, dizziness, nausea, vomiting, coughing, sneezing, use of bathroom, squatting, getting up from sitting position, or head-turning . All of these falls are associated with alcohol use, 3-5 drinks daily. He is always able to get up and may need to use a cane or walker for a few days secondary to pain. School of Medicine 6 3
7/5/2017 • All of the outdoor falls are preceded by lightheadedness without other symptoms. He experiences lightheadedness about 3 times a week, always associated with being up for a long period of time, usually when walking. If he leans against a building the lightheadedness passes in 15 seconds or so. School of Medicine 7 • Medications: • Amlodipine 5 mgs daily • Enalapril 10 mgs twice daily • Omeprazole 40 mgs daily • CaCO3-vitamin D daily School of Medicine 8 4
7/5/2017 SECTION HEADING Presentation Outline • Case presentation • Prevalence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 9 Why falls? The odds of a fracture are 7–9 times higher among community-dwelling postmenopausal women with both a fall and osteoporosis or osteopenia, compared with women having a fall or osteoporosis/osteopenia only. School of Medicine Geusens P, et al. The relationship among history of falls, osteoporosis, and fractures in postmenopausal women. Arch Phys Med Rehabil. 2002;83(7):903–906. 10 5
7/5/2017 Fractures Due to Fall in Older Women ALL FRACTURES WRIST PROXIMAL HUMERUS ELBOW HIP PATELLA ANKLE FOOT/TOES PELVIS FACE HAND/FINGER TIBIA/FIBULA RIB School of Medicine 0 10 20 30 40 50 60 70 80 90 Nevitt et al. 1997 Percent 11 SECTION HEADING Prevalence Falls are Common • ~1/3 of those over 65 will fall in the next year • ~1/2 of those over 80 will fall in the next year • In 2010, ~7 million Medicare beneficiaries fell NEJM 348:42 ‐ 49,2003 Clin Ger Med 18:141 ‐ 158,2002 School of Medicine Am J Prev Med 2012;43(1):59–62 12 6
7/5/2017 0.32 School of Medicine Clinicoecon Outcomes Res. 2013;5:9-18. 13 Self-reported falls in US, ≥ 65 years • In the past 3 months, how many times have you fallen? (16% fell) • How many of these falls caused an injury? 1.8 Million with Injury 4 Million School of Medicine MMWR. 2008;57:225-229 14 7
7/5/2017 Consequences • 1/3 fallers with injuries reported needing help with ADLs as result of fall injury • 1/2 of these expected to need help with ADLs for at least six months • ~10% result in a major injury (fracture, TBI, serious soft tissue injury) • ~350,000 hip fractures annually School of Medicine Adv Data 392; 2007 Fall Injury Episodes Among Noninstitutionalized Older Adults: US, 2001–2003 15 65+ Number Going to ED/Getting Hospitalized for Falls is Increasing 2.5 Millions 2 To Emergency Department 1.5 1 0.5 Hospitalized 0 2001 2003 2005 2007 2009 2011 2013 School of Medicine http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 16 8
7/5/2017 Death from Falls 65+ 30000 25000 Number of Deaths 20000 15000 10000 5000 0 1999 2001 2003 2005 2007 2009 2011 2013 School of Medicine http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 17 School of Medicine 18 9
7/5/2017 Costs – Direct medical costs: 30 billion dollars in 2010 – Indirect and direct est 68B by 2020 School of Medicine Inj Prev 2006; 12(5): 290-5 19 Summary • Falls are common among older adults • Falls affect patient function and are a major mechanism of injury. • Number and rate of falls is increasing School of Medicine 20 10
7/5/2017 SECTION HEADING Presentation Outline • Case presentation • Incidence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 21 Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor No. of Studies RR OR Significant Previous falls 16 1.9-6.6 1.5-6.7 Balance impairment 15 1.2-2.4 1.8-3.5 Decreased muscle strength 9 2.2-2.6 1.2-1.9 Visual impairment 8 1.5-2.3 1.7-2.3 Meds: >4 or psychoactive 8 1.1-2.4 1.7-2.7 Gait impairment 7 1.2-2.2 2.7 Depression 6 1.5-2.8 1.9-2.9 Dizziness or orthostasis 5 2.0 1.5-3.1 ADL disabilities 5 1.5-6.2 1.7-2.5 Age >80 4 1.1-1.3 1.1 Female 3 2.1-3.9 2.3 Low BMI 3 1.5-1.8 3.1 Urinary Incontinence 3 1.3-1.8 JAMA 2010;303:258 Cognitive impairment 3 2.8 1.9-2.1 School of Medicine Pain 2 1.7 22 11
7/5/2017 School of Medicine Osteoporos Int. 2009 Dec; 20(12): 2025–2034 . 23 School of Medicine Osteoporos Int. 2009 Dec; 20(12): 2025–2034 . 24 12
7/5/2017 Risk factors for injurious falls Previous injurious fall increases risk of falling ~ 3X School of Medicine BMC Geriatr. 2014 Nov 18;14:120 25 Trip School of Medicine 26 13
7/5/2017 Video Capture • 2 Long-term facilities in British Columbia • 38 months monitoring of common spaces • 227 falls in 130 people • Correlation between staff investigation and video Lancet. 2013 Jan 5;381(9860):47-54 School of Medicine 27 Incorrect weight shifting 41% (93 of 227) of falls Trip or stumble 21% (48) Hit or bump 11% (25) Loss of support 11% (25) Collapse 11% (24) Slipping 3% (6) School of Medicine 28 14
7/5/2017 Other risk factors • Hypoxia during sleep – Men with ≥ 10% of sleep time with SaO2 ≤ 90% had RR of 1.25, CI = 1.04-1.51 for one or more falls RR of 1.43, CI = 1.06-1.92 for two or more falls c/t men with ≤ 10% of sleep time with SaO2 ≤ 90% JAGS 62:1853, 2014. School of Medicine 29 Frailty • Multiple definitions- all (CHS, SOF, WHI) associated with falls • Women’s Health Initiative (3558 participants) – Weight loss ( ≥ 10lbs or 5% over 1 year) – Exhaustion – Low Physical Activity score • Average follow-up of 12 years • Women with high frailty scores had elevated risk for falls and fractures J Am Geriatr Soc. 2016 Jun 16. School of Medicine 30 15
7/5/2017 SECTION HEADING Presentation Outline • Case presentation • Incidence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 31 Screening Guidelines for Fall Prevention • Guideline for the Prevention of Falls in Older Persons – American Geriatrics Society – British Geriatrics Society – American Academy of Orthopaedic Surgeons JAGS 49:664–672, 2001, updated 2010 • Practice Parameter: Assessing patients in a neurology practice for risk of falls – American Academy of Neurology Neurology 2008;70;473-479 • CDC Stopping Elderly Accidents, Death, and Injuries – July 2015 School of Medicine 32 16
7/5/2017 AGS/BGS Guideline Older person encounters health care provider 2 or more falls last year Screen for risk of falling Presents with acute fall Difficulty with walking or balance No Yes Single fall in past year? Falls Evaluation No Yes Yes Abnormalities in gait or unsteadiness? No Reassess annually School of Medicine 33 American Academy of Neurology Inquire about falls in Review risk factors for falling the past year Neurological: stroke AND dementia gait/mobility problem parkinsonism peripheral neuropathy assistive device LE sensorimotor loss General: (not rated) age >65 vision deficit arthritis, arthralgia depression polypharmacy restricted ADLs Neurology 2008;70;473-479 School of Medicine 34 17
7/5/2017 • If A or B positive: Falls Evaluation School of Medicine 35 Fallers unlikely to discuss falls • Less than half of Medicare beneficiaries who fell saw a healthcare provider about falls (women>men). • Only a third to a quarter who have fallen, report discussing fall prevention strategies with a healthcare provider. Am J Prev Med 2012;43(1):59–62 School of Medicine 36 18
7/5/2017 Other screening tests • Standing unassisted • Timed Up and Go • 325 community • Time to stand from elders, 60 or older chair, walk 3m, and sit back down • Time to stand from sitting, unaided, • Cutoff 12 sec had without use of arms sensitivity of 83% and specificity of 93% • Unable or >2 sec had an OR of 3.0 Nevitt, JAMA 1989 Wrisley, Phys Ther 2010 School of Medicine 37 http://www.cdc.gov/injury/STEADI School of Medicine 38 19
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